Industry Voices—Can you put the genie back in the bottle, or is telemedicine here to stay?

The question is not whether telemedicine will replace conventional in-person medicine, but rather the ability of telemedicine to augment the yield of an in-person evaluation. (Getty/andrei_r)

People have been talking about telemedicine for decades. Those who were proponents of telemedicine never fully understood why it was so slow to take off.

Our sleep clinic has been involved in telemedicine since 2008. We have had bumps in the road, as well as changes in state-determined policies that caused us to suspend our program at one point.

The obvious obstacles were payer reimbursement and the expense involved in setting up a telemedicine program. For those of us who have made telemedicine a routine part of our practice, however, we now realize that these obstacles were smaller than we had anticipated.

Telemedicine equipment used to be exorbitantly expensive. Now, telemedicine platforms are accessible via computer or smartphone at minimal cost.

Payers previously would only reimburse for telemedicine visits if all of their strict criteria were met: The patient had to be in an underserved community designated as a health professional shortage area, had to be in a medical facility for a “center to center” virtual visit and must have had a previous in-person encounter with the practitioner in order to establish a doctor-patient relationship. Billing had to be submitted with an additional modifier, and the facility fee may have been unreimbursed. Claims often were rejected if all of the boxes were not checked.

Each well-intentioned provision had an unintended consequence: It added yet another barrier to care.

Patients still needed to take time away from work, drive to the medical center, wait and then have a telemedicine encounter. And yet, we were happy to at least shorten the drive, reduce the wait and begin to make it easier for patients to receive medical care.

Then the novel coronavirus (COVID-19) arrived on the scene, creating a national emergency that has dramatically and almost instantaneously lifted these barriers.

Public health officials and government leaders have promoted widespread adoption of social distancing while urging patients to stay home except for emergency care.

To support these public health directives, payers have responded with sweeping changes to telemedicine reimbursement, leading to an abrupt shift in the way we practice medicine. We can now see patients as they stay safely at home by using popular audio-video apps such as FaceTime and Skype.

As we recognize the inherent but previously underestimated risks of direct patient interaction, we start to appreciate the safety afforded to clinicians and patients by evaluating patients from afar. This has also led to a reexamination of what is required to assess a patient, render a diagnosis, order testing and provide treatment options.

We are slowly reacquainting ourselves with the importance of the clinical history. We fall back upon our ability to observe our patients—are they tachypneic? Are they speaking in complete sentences? Can we coach our patients to show us their oropharynx? Their legs? Can we teach them how to assess for peripheral edema?

As it turns out, the answer is yes.

The benefits of telehealth as regular medicine

There will always be the need for physical interaction with patients, especially those with abdominal pain or orthopedic injuries that require intervention, for example.

The art lies in determining how much information can be gleaned from afar, thus minimizing patient contact, even if the patient ultimately needs to be seen in person.

We have before us the immediate opportunity to divert patients from an already overwhelmed healthcare system by triaging them via telemedicine. We can order imaging, lab testing and medications via telemedicine. We can make a reasonable agreement with our patients that if conservative measures are not helpful, then they need to be reevaluated, possibly in person.

The question is not whether telemedicine will replace conventional in-person medicine, but rather can telemedicine augment the yield of an in-person evaluation? Is there a role for telemedicine as part of our algorithm? Why does it have to be one or the other?

Don’t our patients deserve medical care that meets them where they are? Shouldn’t we be more mindful of their time and financial constraints? If patients are willing to do this, why are we stubbornly clinging to our traditional methods of assessing them?

As many of my colleagues have been pulled to the front lines to care for COVID-19 patients, we owe it to them to start reevaluating our processes.

Experts believe that we will be contending with this viral outbreak for the next 18 months.

Once this acute phase is behind us, we need to be more receptive to new clinical paradigms that keep our patients and clinical staff safer. The uproar about personal protective equipment has been justified and should make us all recognize our obligation to keep our clinicians safe.

We have all looked at our protocols for screening patients and have examined our current intake processes. COVID-19 has truly been an ignition event. Never before have we seen such rapid collaboration toward shared goals: optimal patient care, development of a vaccine, keeping front-line workers safe and transparency with multiple parallel projects.

Although many of us are working from home and balancing our children’s distance learning with remote patient care, we must support our front-line colleagues by keeping a critical eye on emerging best practices.

Why do we have such large waiting rooms? How many clinic visits are for mental health? How many are for insomnia? When does an in-person encounter actually change patient management? Some patients do need to be seen in person, but the others can likely be well-managed with telemedicine.

Center-to-home telemedicine has moved from an aspirational, long-term goal to immediate reality with great urgency. Once more practices adopt this model and become more comfortable with the technical aspects of a telemedicine visit, the clear advantages will be obvious.

By adhering to new best practices, we will continue to innovate and improve patient care while also keeping our clinical staff safer. I don’t think we will be able to put the genie back in the bottle, and that is probably a good thing.

Seema Khosla, M.D., is the medical director at the North Dakota Center for Sleep. Khosla also is a medical adviser for MedBridge Healthcare, which provides integrated sleep lab management services to hospitals, healthcare systems and physician groups.